Private Health Insurance - Cover for Prostheses

What are prostheses?

A prosthesis is an artificial substitute or replacement body part attached or applied to the body to replace a missing part.

If you are having surgery to implant or apply a prosthesis, your private health insurer must pay a benefit for it if:

you have the correct cover the for treatment, and

the product is on the Prostheses List.

The Prostheses List includes more than 10,000 surgically implanted prostheses, human tissue items and other medical devices. It also shows the minimum benefits that private health insurers must pay for each prosthesis.

What is on the Prostheses List?

The types of prostheses on the Prostheses List include (but are not limited to):

hip, knee and other joint replacement devices

cardiac implantable electronic devices such as pacemakers and defibrillators

What is not on the Prostheses List?

Devices such as external limb prosthetics, external breast prostheses and implants used solely for cosmetic purposes are not on the Prostheses List.

How much will the private health insurer pay?

The private health insurer must, by law, pay the minimum benefit listed on the Prostheses List for a prosthesis.

Will I have any out-of-pocket expenses?

If the minimum benefit listed on the Prostheses List covers the cost of the prostheses to the hospital, then you will not have any out-of-pocket costs.

If the minimum benefit does not cover the cost of the prostheses to the hospital, then you might need to pay all or part of the gap. The gap is the difference between the minimum benefit and the cost of the prostheses which will be decided by the hospital.

What should I do to find out more about private health insurance cover for a prosthesis?

Talk to your private health insurer

Before you have surgery involving a prosthesis, talk to your private health insurer to make sure you have the right cover for the operation and any associated treatments.

Some private health insurance products exclude or restrict benefits for some types of treatment, such as joint replacement surgery (hips, knees and other joints) and treatments for cardiac ailments. If your insurance product excludes benefits for your treatment, you will not be paid a private health insurance benefit for the prosthesis.

If you have restricted cover for your treatment, a private health insurance benefit will be payable for the prostheses, but benefits for other aspects of your treatment and stay in hospital will likely be limited.

Talk to your treating doctor

When your doctor confirms that you require a prosthesis implant, ask if the prosthesis is on the Prostheses List. If it is not, ask the doctor if there is a prosthesis that can be used that is listed.

The doctor might know whether the minimum benefit on the Prostheses List will cover the cost of the prosthesis, but in most cases the doctor will not have information about the cost of the prosthesis.

Talk to the hospital

Before you are admitted to hospital for any procedure, it is important to confirm with the hospital the costs of your procedure and your stay. You should also check if there will be any out-of-pocket costs that you will have to pay, including the prosthesis.

Check again with your private health insurer

Check with your private health insurer about the benefits that will be paid for your surgery and your admission to hospital and if there is anything that your private health insurance won’t cover.

What can I do if the private health insurer won’t pay for the prostheses or medical device?

If the prosthesis or medical device is not on the Prostheses List, the private health insurer is not required by law to pay the claim.

You can ask the private health insurer to pay the claim on a goodwill basis, but this will be entirely up to the insurer.

It is the responsibility of the patient to check their level of private health insurance cover prior to having the prosthesis surgery.